Public Servant’s Questionnaire

Authority – Privacy Act, 5 USC Sec. 552a, 88 Stat. 1896 (1974)

• P u b l i c s e r v a n t ’ s f u l l l e g a l
name:___________________________________________________________________
__
• P u b l i c s e r v a n t ’ s r e s i d e n t
address:_________________________________________________________________
_
• N a m e o f
Agency:_________________________________________________________________
_____________________
• N a m e o f S u p e r v i s o r a n d O f fi c e
Address:____________________________________________________________

______________________________________________________________________________
____________________________
5. Will public servant uphold the Constitution of the United States?
________________________________
6. Did public servant provide Citizen with proof of Identity?
________________________________________
7. ID Number___________ Badge Number_______________Bonding Agency and
Number_______________
8. Will public servant furnish a copy of the law or regulation that authorizes information
request?_________________
9. Will public servant read aloud the portion of the law authorizing the questions
ask____________
10. Are Citizens answers voluntary or mandatory?
_____________________________________________________
11. Are questions being asked based upon a specific law or regulation, or are they a discovery
process?__________________________________________
12. What other uses may be made of his information?
_________________________________________________
13. What other agencies may have access to this information?
________________________________________
14. What will be the effect upon me if I should not choose to answer any of or all of these
questions?

______________________________________________________________________________
________________________________
15. Name of person in government requesting this
information__________________________________________
16. Is this investigation of my finances general or special?
________________________________________________
17. Have you consulted, questioned, interviewed, or received information from any third
p a r t y r e l a t i n g t o t h i s m a t t e r ?
______________________________________________________________________________
______
18. If yes, give identity of all such third
parties______________________________________________________________
19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued
based upon any of the information which you seek?
____________________________________________________________
20. Is there a file of records, information, or correspondence relating to me being maintained
b y t h i s A g e n c y ?
______________________________________________________________________________
_______________________
21. Is this agency using any information on me which was supplied by another agency or
g o v e r n m e n t s o u r c e ?
______________________________________________________________________________
_______________________
22. Will the public servant guarantee that the information in these files will not be used by
any other department other than the one by which he is employed?
_____________________________________________

I hereby sign and affirm under penalty of perjury that the answers given are true and
correct in every particular.

_____________________________________________________
Signature of public servant

Notice: If any request for information relating to me is received by any person or agency, you
must advise me in writing before releasing such information. Failure to do so may subject you to
possible civil or criminal action as provided by this act or the law.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______